A nurse is collecting data from a client who is 24 hours postpartum.
Which of the following findings should the nurse expect?

Choice A rationale:

Umbilical cord compression is a serious condition that can deprive the fetus of oxygen and nutrients. It can occur during labor

due to various factors, such as excessive fetal movement, a long umbilical cord, or decreased amniotic fluid.

Key signs of umbilical cord compression include:

Variable decelerations: These are abrupt decreases in the fetal heart rate (FHR) that vary in duration, depth, and timing. They

are often caused by cord compression, as the compression temporarily reduces blood flow to the fetus.

Late decelerations: These are delayed decreases in the FHR that occur after the peak of a uterine contraction. They can also be

a sign of cord compression, as the compression can impair placental blood flow.

Loss of FHR variability: This refers to a decrease in the normal fluctuations of the FHR. It can be a sign of fetal distress,

including cord compression.

Immediate action is crucial when umbilical cord compression is suspected. The nurse should:

Notify the provider immediately.

Change the mother's position: This can help relieve pressure on the cord. Common positions include:

Lateral positioning (lying on the side)

Trendelenburg position (lying on the back with the head tilted down)

Knee-chest position (kneeling with the chest on the bed)

Administer oxygen to the mother: This can increase fetal oxygenation.

Prepare for possible interventions: These may include amnioinfusion (infusing fluid into the amniotic sac to increase fluid

volume), internal fetal monitoring, or cesarean delivery.

Choice B rationale:

Head compression is a common occurrence during labor as the fetal head descends through the birth canal. It usually does not

require intervention unless it causes significant changes in the FHR or other signs of fetal distress.

Choice C rationale:

Maternal opioid administration can affect the FHR, but it is not typically a cause for immediate concern unless there are

significant changes in the FHR or other signs of fetal distress. The nurse should continue to monitor the FHR closely and report

any concerns to the provider.

Choice D rationale:

Lateral decelerations are not a recognized pattern of fetal heart rate decelerations. The correct term for decelerations that

occur after the peak of a contraction is "late decelerations."

Choice A rationale:

Performing hand hygiene before and after voiding is crucial in preventing perineal infection. Hand hygiene is the most

effective way to prevent the spread of infections, including those that can infect the perineum.

Choice B rationale:

Cleaning the perineal area from front to back is a standard recommendation to prevent infection. This method ensures that

bacteria from the anal area are not spread to the vagina and urethra, which can cause urinary tract infections.

Choice C rationale:

Sitting on an inflatable donut is not typically recommended for the prevention of perineal infection. While it can provide

comfort for those with perineal pain, especially after childbirth, it does not directly contribute to the prevention of infection.

Choice D rationale:

Applying ice packs to the perineal area several times daily can help reduce swelling and provide pain relief, especially after a

vaginal birth. While it does not directly prevent infection, it can promote healing and comfort, which can indirectly help

prevent infection.

Choice E rationale:

Blotting the perineal area dry after voiding is another important step in preventing perineal infection. Keeping the area dry

prevents the growth of bacteria and other microbes that thrive in moist environments.